With the rate of c-sections higher than ever before, many major health organisations are looking at ways to reduce c-section rates.
The World Health Organization recommends a c-section rate of around 10-15%.
Having a c-section rate greater than 15% suggests that women are being subjected to unnecessary intervention.
Having a c-section rate of less than 10% suggests that women and babies who might benefit from c-section birth might not have access to the procedure.
One piece of the puzzle for reducing c-section rates is finding out what’s leading to such high rates.
In countries such as the US, UK and Australia, c-section rates have reached an average of around 30%, which is double the recommended rate. This also means around one in three babies is being born via major surgery.
Hospitals in these countries have rates that can range from 15% to over 50%. With the average being around 30%, this suggests that more than half of women giving birth via c-section are doing so unnecessarily, and they’re exposed to risks that do not outweigh the benefit of this surgical procedure.
Do Inductions Increase The Risk Of C-Section?
With induction and augmentation of labour being more popular than ever before, one question major medical organisations are asking is whether inductions increase the risk of c-section birth.
What Does Current Evidence Show About Outcomes Of Induction Of Labour?
A new study concluded induction of labour does not increase the risk of c-section or instrumental assisted birth.
However, we need to look at how the study was conducted to see why this might not be a clear answer.
Researchers studied 619 first time mothers over the age of 35, who had reached 36 weeks of pregnancy. They divided them into two groups: either to be induced at 39 weeks, or to receive ‘expectant management’ care.
The results between the two groups were quite similar. The first group, assigned to be induced at 39 weeks, had a c-section rate of 32%, and a vaginal birth with instrument assistance rate of 38%.
The second group, which received expectant management care, had a c-section rate of 33% and a vaginal birth with instrument assistance rate of 33%.
Based on these results, the study concluded that a scheduled induction at 39 weeks does not increase the risk of a c-section.
However, this study had a major flaw.
What wasn’t discussed, and which has a real impact on the meaning of these results, is the fact that the women remained in their assigned group based on the intention of care, not on how their labour actually started.
The first group, those assigned to be induced at 39 weeks, had a 20% rate of spontaneous labour. This means that women who began labour spontaneously were included in the statistics that showed no increase in c-section birth with a scheduled induction.
Even more surprising, of the group assigned to expectant management care, 49% (half) of the women were induced. Women who were induced, despite the intention of care assignment, were included in the non scheduled induction statistics, which were then used to conclude no increased risk of c-section.
Essentially, this study shows that intent to induce at 39 weeks doesn’t necessarily increase the risk of c-section birth. However, it doesn’t exactly prove that inducing labour doesn’t increase the risk of c-section birth.
Why Normal, Physiological Birth Matters
Modern obstetrical care can be a vital part of maternity care. We know that some women and babies are saved every year, thanks to inductions, assisted birth and c-sections.
Women with pre-eclampsia, or HELLP, and babies experiencing true fetal distress and other conditions warrant interventive care to ensure the health and safety of both mother and baby.
However, with the rise of expectant management care, not only for women who are high risk, but for the majority of women, we have actually seen the health of mothers and babies put at risk.
While this study showed comparable c-section rates in both groups, it fell in line with the over 30% c-section rate we often see. If we compare these rates with the recommendations of the WHO, it seems many of these women could have been subjected to a c-section which was not medically necessary.
Rather than comparing planned induction with planned expectant management care, we can gain a clearer picture of the role of inductions in relation to c-sections by comparing planned induction with supported normal physiological birth. Expectant management care often interferes with normal physiological birth.
Birth is a normal bodily process, and any intervention can affect how your body and your baby respond to the birth. Physiological birth means:
- Birth begins spontaneously
- The birthing mother has full autonomy
- The birth environment is conducive to facilitating the release of oxytocin, melatonin, and endorphins, and reduces the risk of releasing adrenaline. This means it should be dim, quiet, calm, and free of interruptions
- The birthing mother is able to choose which labouring and birthing positions she finds most comfortable
- She is not confined to the bed
- She doesn’t receive medications which interfere with contractions (epidural, synthetic oxytocin, etc)
- Exams are performed in a way that does not interfere with her ability to cope with contractions (i.e. performed with consent, only when medically necessary, and not during an active contraction)
- The mother pushes with her body’s urges, and rests as she desires
- Baby is placed on mother’s chest after birth: this encourages the oxytocin to continue to flow and help with expelling the placenta; it also helps baby to maintain body temperature and regulate her breathing
Expectant management often interferes with normal physiological birth.
What Are Your Health Care Provider’s Beliefs About Birth?
If maternity care providers are trained to believe that birth is a normal physiological process that often unfolds safely, they’re likely to utilise modern obstetrical intervention only when medically necessary.
When maternity care providers are trained to manage birth to prevent any potential adverse outcomes, they’re likely to utilise intervention, in the hope of avoiding adverse outcomes. In the process, they might increase the risk of other complications. Obstetricians are trained surgeons (and thank goodness they are), but even when they care for low risk women, those women are more likely to end up having a surgical birth.
Most midwives are trained to approach birth as a normal physiological process. We see this in their improved birth outcomes when compared with OB care for low risk women. Women who utilise midwifery care are less likely to be induced or have their labour augmented, less likely to have a c-section birth, and less likely to have an assisted vaginal birth. These consistently improved maternal outcomes show that normal physiological birth for low risk women can lead to lower c-section rates.
While this study shows equal outcomes for planned induction compared with expectant management, it fails to show that induction increases the risk of c-section when compared with normal physiological birth.
Modern obstetrical care has an absolute role in saving the lives of women and babies, but these interventions aren’t without risk. In situations where ending the pregnancy is safer than continuing (preeclampsia, HELLP, true fetal distress, etc), the benefit of induction or c-section birth outweighs potential risks.
When there isn’t a medical need to induce, whether we’re certain about an increase in c-section or not, we are exposing mothers to risks which might outweigh the benefits of an induction.